Online Referral Form

Blue Mountain Therapy Application for Services

We value your privacy and your time! In an effort to streamline the referral process, please find our online application below. You will need to accept the Adobe Terms of Service to get started. Once you fill out the required fields, submit the application, and a Blue Mountain Therapy representative will reach out. If you have any questions, or would like help with this process, don’t hesitate to reach out to us by phone or email.

Phone: (276) 525-6043 | Email: info@bluemountaintherapy.com

Online Referral Form

Blue Mountain Therapy Referral Form

Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Primary DX
Secondary DX
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Contact Name*
First Last
Emergency Contact Name:*
First Last
Phone*
Email*
Relationship to Client*
Referral Type*
- Home Health Referral
- ABA Referral
- Outpatient Referral
Please evaluate patient for: (check all that apply)*
- Select All
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- MSW (Social Worker)
- Skilled Nursing
- Home Health Aide
Face-to-Face Date of Visit:
MM slash DD slash YYYY
Reason for Face-to-Face Encounter:
Clinical findings to support Home Health Services:
Parent/Guardian's Name*
First Last
Gender*
- Male
- Female
Age
Diagnosis Code
Presenting Problems/Behaviors/Communication Deficits/Delays:
Preferred Treatment Facility:
- Abingdon
- Wytheville
- Norton
Please evaluate patient for (Check all that apply):*
- Select All
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Behavioral Therapy
Face-to-Face Visit Date:
MM slash DD slash YYYY
Reason for Face-to-Face Encounter:
Clinical findings to support need for Outpatient Therapy:
Referring Physician's Name*
First Last
Physician's Phone #*
Office Name & Location:
Please provide current copy of insurance card(s)
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 256 MB, Max. files: 2.
Please provide most recent encounter note
Accepted file types: jpg, png, pdf, Max. file size: 256 MB.
Administrative Use Only:
When filled out online, Blue Mountain Therapy will contact your referring physician for their signature.
Physician's Signature
Date
MM slash DD slash YYYY
Referral Faxed By:
Email
Email
This field is for validation purposes and should be left unchanged.

Blue Mountain Therapy strives to be your Provider of Choice. We offer therapeutic services for children and adults in home and in outpatient settings. Serving Abingdon, VA and neighboring regions of SWVA.

Contact Us

Serving Patients From

Abingdon, VA

Bristol, VA

Norton, VA

Wytheville, VA

Marion, VA

Lebanon, VA

Southwest VA

Northeast TN

Online Referral Form

Blue Mountain Therapy Application for Services